An Outline of Administrative Guides for the Community Cerebral Palsy Program SAMUEL M. WISHIK, M.D., M.P.H., F.A.P.H.A. different clinical patterns and disease "The chief bottleneck to more ade- pictures. Arbitrarily, in this presenta- quate care (of the cerebral palsied tion, the term cerebral palsy is limited child) is not funds, but qualified to conditions resulting from damage to personnel," concludes this writer. "At present recruitment is a greater the growing or developing brain and problem than finding suitable excludes disorders of muscular control training facilities." which occur in adult life, such as hemi- plegia from arteriosclerotic vascular disease. + The Committee on Child Health of The child with cerebral palsy almost the American Public Health Associa- always is a child with multiple handi- tion, with the help of many persons caps (Table 1). throughout the country, is preparing a guide for public health administrators Table 1-Cerebral Palsied Children on community programs for cerebral Estimates of Proportion Having Other Disabilities than Neuromuscular palsied children. Partly from that man- Disturbance Alone uscript there has been selected for pre- Per cent sentation here information on certain Speech defect 50-75 outstanding questions or problems that Mental retardation About 50 Visual defect, are frequently faced by the public health other eye disturbances, or both " 50 administrator. An attempt is made to Convulsions " 35 answer some of the questions, or at Hearing impairment " 25 least to present a point of view or com- posite of experiences. For brevity's The frequency of multiple handicaps sake, the material is organized in outline among cerebral palsied children imme- form. / diately raises the question in the mind Prevalence-As nearly as can be of the administrator concerning the determined from existing studies, there advisability of giving care to cerebral are between 1.5 and 3.0 cerebral palsied palsied children together with other persons of all ages per 1,000 total popu- handicapped children or by themselves. lation. It is estimated that cerebral In combined programs, common serv- palsy results in one of every 170 live- ices can be utilized more efficiently for born infants. Dr. Wishik is professor of maternal and Definition-Cerebral palsy is a child health, Graduate School of Public group of conditions resulting from Health, University of Pittsburgh, Pittsburgh, Pa. brain disturbance and having in com- mitteeThis paper was reported for the Com- on Child Health of the APHA and mon a disorder of muscular control. presented before a Joint Session of the American School Health Since the condition is caused by a num- Dental Health, Maternal Association and the ber of different and often unrelated fac- and School Health Sections of Child Health, and the American tors operative before birth, during Public Health Association at the Eighty-first birth, or after birth, there are many Annual Meeting in New York, N. Y., Novem- ber 10, 1953. 158 CEREBRAL PALSY PROGRAM VOL. 44 159 Table 2-Elements of Community Program for Children with Cerebral Palsy Desirability of Separateness or Combination with Activities for Other Types of Handicapped Children A. Should be combined B. Usually should be combined, but may Case finding be separate, depending on numbers Case register and other factors General health supervision Specialized medical supervision Otologic and ophthalmologic consulta- Physical therapy, occupational therapy, tion and care and speech therapy Furnishing braces Dental care Surgery Special daytime education Daytime education in regular classes Education in residential school Recreation Vocational aid Counseling, social work, or psycho- Institutional care for mental retardation therapy to child or Long-term institutional care for severe C. Should be separate family physical disability Specialized diagnosis Public education Research (may be combined) Prevention Professional training (may be combined) different types of children. For exam- of different ways in which cerebral ple, both children with cerebral palsy palsied persons have been classified. and with poliomyelitis can be treated Each method is useful to the administra- by the same physical therapist. The tor or therapist for one or another argument in favor of the specialized purpose (Table 3). service is that the child with cerebral palsy presents problems of such com- Table 3-Methods of Classifying plexity and special nature that a com- Cerebral Palsy Medical pletely separate approach is necessary. Descriptive nature of neuromuscular dis- It is here suggested that neither turbance method is appropriate for all the needs Parts of body involved Associated handicaps of the cerebral palsied child. The Severity of involvement various services required by one or Anatomic site of brain lesion another cerebral palsied child are here Degree of tonicity Etiology classified according to efficiency and ad- Educational vantage of separate or combined organization (Table 2). The classification (Table 4) devel- Classification-There are a number oped largely by Winthrop M. Phelps, Table 4-Classification of Cerebral Palsy Descriptive Characteristics of Neuromuscular Disturbance Type Characteristics Percentage Distribution Tendency of muscles to contract when put under Spastic tension (stretch reflex) 45-65 Athetoid Involuntary, incontrollable, irregular motions 25-35 with varying degrees of muscle tone Ataxic Disturbance of balance and postural sense 5-15 Rigidity Tremor Resistance to slow movement 5-15 Mixed types (Adapted from M. Perlstein, M.D.) 160 FEB., 1954 AMERICAN JOURNAL OF PUBLIC HEALTH M.D., is the most commonli y used one grouping associated disabilities, and and helps in differentiati ng needed identifying etiological factors. therapies and educational placement, Traditional nomenclature has grown up like Topsy. A diplegia can be a Table 5-Classification of Ce2 rebral Palsy paraplegia or not. A hemiplegia (half) Parts of Body Involved in Neuw romuscular has as many limbs involved as a diplegia Disturbance (twice). The Greek word "paraplegia" Para plegia Legs only (Spastic) means "hemiplegia" (Table 5). Di plegia Legs mainly, arms slightly (Spastic) The terms require additional descrip- Quadri plegia Legs more (Spastic) tion to locate the affected limbs. A Arms more (Athetoid) more logical terminology is offered Hemi plegia Arms more (Spastic) in Table 6. Tri plegia Both legs, one arm (Spastic) The classification shown in Table 7 Hemi plegia Arms more (Spastic) is helpful in assessing community needs, (double) estimating required types and numbers Mono plegia (Rare) (Spastic) of professional personnel, and in plac- (Adapted from M. Perlstein, M.D.) ing children. The following is of interest chiefly to Table 6-Suggested Classiification of the physical therapist and occupational Cerebral Palsy and Paralytic Conditions therapist (Table 8). Limbs Affected Monoplegia Table 8-Classification of Cerebral Right brachial Palsy-Tonicity Left brachial Hypertonic or tension types Right skelial * Normotonic types Left skelial Hypotonic or "atonic" types Diplegia Right Left Etiology, in so far as known, aids the Brachial administrator to plan preventive meas- Skelial Triplegia ures and education, as is shown in Di-brachial and right skelial Table 9. Di-brachial and left skelial This classification not only helps in Di-skelial and right brachial development of appropriate educational Di-skelial and left brachial Quadriplegia programs, but gives basis for introduc- ing medical treatments into school * Derived from Greek word "Skelos," meaning leg settings (Table 10). Table 7-Classification of Cerebral Palsy Severity of Involvement and Response to Treatment Per cent Mild Ambulatory and self-helpful Need little or no special treatment 20 Moderate Difficult speech, impaired self- Need and can probably profit help or ambulation, or both from treatment; usually out- patient care 50 Severe Severely incapacitated and Treatment may not rehabili- bedridden tate; usually inpatient care 30 (Adapted from M. Perlstein, M.D.) CEREBRAL PALSY PROGRAM VOL. 44 161 Table 9-Classification of Cerebral Palsy Table 11 Cerebral Palsy Services Etiology Desirable Geographic Accessibility Congenital A. Must be local to be of use malformation Case finding General health supervision Prenatal Direct physical therapy, occupational (e.g., cord obstruction, therapy, speech therapy abruptio placenta) Dental care Perinatal anoxia Natal Recreation (e.g., breech, narcosis) Counseling, social work, or psycho- Neonatal therapy (e.g., atelectasis, Daytime education (regular or special) tracheal obstruction) Public education Prevention Natal B. Preferably organized on a Trauma, toxicity, or (e.g., dystocia, toxe- regional basis vascular disturbance mia, hemorrhage, pre. Specialized diagnosis cipitate, caesarean) Specialized medical supervision Childhood accident Indirect (consultation or supervision or both) physical therapy, occupational Specific toxicity or (e.g., encephalitis, therapy, speech therapy infection lead encephalopathy) Furnishing braces and other appliances (Adapted from Ml. Perlstein, M.D.) Surgery Residential education Vocational aid Certain services, such as education, Institutional care may be needed almost every day and Research Professional training therefore must be near the child's place of residence. Other services, such as a specialist's consultation, may be called services and can constitute valuable upon infrequently and could therefore indexes for further planning (Table 12). be obtained from a distance. The ad- Case finding is everybody's job. It ministrator must differentiate those rests upon sound general community services that can be organized region- services in health, education, and wel- ally rather than locally and still be fare and it requires orientation of pro- considered a reasonable part of the fessional workers in those programs to community program for handicapped the needs and potentialities of cerebral children (Table 11). palsied children. Over and beyond the Preplanning community surveys are "broadside" case finding, the adminis- costly and often not too productive. In trator can aim at specific targets. In the absence of a broad survey, consider- so far as we know the common pre- able data can be derived from existing cursors of brain damage, patients with Table 10-Classification of Cerebral Palsy Educational Potential and Needs Fully and readily Normal mentality; Usually can fit into educable minor disability regular school program Fully but not Normal mentality; moderate readily educable or severe physical, sensorial, Need special education or emotional disability Not fully educable Mild or moderate Educational placement de- mental retardation pends on physical needs Not educable Severe mental or physical disability, or both Need custodial care 162 FEB., 1954 AMERICAN JOURNAL OF PUBLIC HEALTH Table 12-Cerebral Palsy Table 13-Cerebral Palsy Case Finding Specific Indexes to Community Need for Intensive Follow Up of "Vulnerable" Infants Strengthened Program Maternal disease (e.g., German measles) 1. Occurrence of preventable types of Erythroblastosis fetalis cerebral palsy Severe fetal stress during birth 2. Delay in diagnosis and reporting, es- Neonatal anoxia, convulsions, etc. pecially before school age Small premature infants 3. Errors in diagnosis 4. Registered or known children who are up in a timetable. The following time- not under care 5. Children under care, but with gaps in table for all cerebral palsied children components of total rehabilitation helps in program development and in 6. Unnecessarily restricted educational placement (home instruction, separate classes, assessing the needs of groups of patients. It should be individualized for seeking etc.) 7. Unemployed cerebral palsied adults continuity of effective supervision of 8. Waiting lists for institutional care each given child (Table 14). 9. Excessive caseloads in existing programs Because of the multiple handicaps of 10. Incomplete geographic coverage the cerebral palsied child, assessment 11. Ineligibility of children because of race, and treatment of each of his disabilities economic status, or other reason 12. Poor coordination of existing resources is often beclouded by disturbance of the 13. Substandard quality of existing services usual avenues of communication, ap- in respect to facilities or personnel praisal, or care. For example, response to physical therapy is lessened if the suspicious history can be labeled as child does not hear or understand the "vulnerables" and be given more than therapist's instructions. Schooling is routine follow-up attention. Table 13 interrupted by frequent convulsions. is an example. Testing of intelligence by verbal or Cerebral palsied children carry their manual methods is difficult in the condition all their lives. As they grow, presence of speech or hand disturbance, their needs for help in treatment and respectively. adjustment change. The general nature Modification of usual methods be- of their needs can be predicted from comes necessary and each profession one age level to another and can be set obtains aid from nontraditional quar- Table 14-Cerebral Palsy General Timetable of Care Reasonably prompt recognition At onset (birth Intensive follow up of "vulnerable" infants or later) Interpretation to family General health supervision (throughout) Periodically Professional team evaluation and recommendation of plan of care Specialized health supervision (throughout) Preschool Parent counseling (throughout) years Consideration of readiness for therapies (physical, occupational, speech) and nursery education Therapies (physical, occupational, speech) School years Education Psychological and social adjustment Adolescence Introduce vocational planning, counseling, and training Social and recreational outlets Adulthood Vocational placement CEREBRAL PALSY PROGRAM VOL. 44 163 Figure 1-Cerebral Palsy Diagnostic Center Role in Community Program CASE-FINDING AND REFERRAL SOURCES DIAGNOSTIC TREATMENT SERVICES CENTER COMMUNITY TREATMENT RESOURCES ters. Table 15 shows how testing diagnosis to enable the center staff to the intelligence of the cerebral palsied keep their work on a sound basis child calls for longitudinal study, atten- (Figure 1). tion to cultural factors, observations by Different auspices for the center are other professional and lay persons, and possible, depending on the types of re- individualized considerations. sources in the region. Possible auspices are: a hospital (especially a teaching Table 15-Cerebral Palsy hospital), the public schools, a resi- Aids in Assessment of Intellectual Capacity dential institution for handicapped chil- Serial retesting-growth more significant dren, or an independent (voluntary) than single rating agency. In general, the hospital is to be Emphasis on physical, environmental, emo- preferred in order to permit economical tional, and social factors Observation of child's response to training use of medical personnel and facilities situations during treatments in home, clinic, (Table 16). and school Comprehension of language and child's Table 16-Cerebral Palsy Diagnostic ability to devise means of communication. Center Basic Professional Team (Adapted from Charles R. Strother) Public health nurse Pediatrician The hub of the community cerebral Social worker palsy program is the multiprofessional Psychologist diagnostic center which makes appraisal Orthopedist or physiatrist Physical therapist of disabilities and potentialities and Speech therapist recommends a plan or campaign of Additional Professional Workers care, both immediate and long term. or Consultants Because of the varied types and loca- Neurologist tions of treatment needed, the majority Psychiatrist of patients seen at the center must be Ophthalmologist referred to community resources for Otologist Dentist care. A smaller portion of the patients, Bracemaker especially those living nearby, should be Occupational therapist given on-going treatment as well as Vocational counselor Educator of exceptional children 164 FEB., 1954 AMERICAN JOURNAL OF PUBLIC HEALTH Figure 2-Cerebral Palsy Diagnostic Clinic Example of Procedure Ten patients seen per session-screened before admission by medical referral Individual Interviews and Examinations All patients seen by Selected Patients Pediatrician 10 Patients in 3 Hours seen by Social worker 10 " " 4 " Speech therapist 6 Patients in 2 Hours Physical Psychologist 5 " " 212 " therapist 10 " " 3Y2 TIME SCHEDULE: 8:00 SOCIAL WORKER PHYS. PEDIA- 9'00 THERA- TRICIAN I I PIST PSYCHO- 10:00 I I I REFERRAL LOGIST I SPEECH OTHER THERA- CONSULT- 11:00 I I __ I I PISTS I ANTS I t 1! 12'00 __, s 1:00 ABOVE STAFF AND: STAFF PUBLIC HEALTH NURSE 2:00 CONfERENCE ORTHOPEDIST 3:00 SEES ALL NEUROLOGIST, AND OTHER PATIENTS APPROPRIATE CONSULTANTS 4:00 Moving from a single clinician to a the majority of cerebral palsied children professional team requires coaching, should be the day school. Some chil- training, signals, and ground rules. dren will fit into regular classes and More often than not, the workers con- others may be grouped with other types stitute the wrong kind of "interference" of handicapped pupils. The last table for each other, with a consequent poor gives criteria for admission to a special score. The care with which a diagnostic cerebral palsy unit when such a facility clinic must be organized is suggested is found feasible to set up (Table 17). in Figure 2. Medical and social factors play a Table 17-Special School Unit for large role in determining most appro- Cerebral Palsy priate educational placement. The ob- Criteria for Admission of Children jectives in educational placement are: As normal an educational setting as pos- 1. Will the special services help improve his health or educational status? An estimate sible; grouping of children for special of prognosis should be made in terms of: education and services rather than by Ultimate outcome expected for the child diagnoses; maintenance of children's Immediate and long-term objectives for him community and home ties; flexibility in How much of his improvement may be ex- change of educational placement; and pected to develop spontaneously and how medical supervision of health and med- much would depend on special training in the unit ical services given in school. Estimated timing of child's progress While the diagnostic center is the hub 2. Can the special unit handle the child? of the community program, the most im- Indexes of this aspect of the problem include: portant single resource at some time for Transportation between home and school CEREBRAL PALSY PROGRAM VOL. 44 165 Facilities and space in the classroom and training to expect enough iidividuals to school move on to specialized graduate work. The child's ability to handle himself per- Much research is needed to fill gaps sonally Availability of therapies needed by the child in our information. Nevertheless, many Behavioral problems of the child cases of cerebral palsy can be prevented The child's educational adjustment by more effective use of existing knowl- 3. Will admission help the child or his edge. family, or both, in the absence of actual im- BIBLIOGRAPHY provement of his condition by: 1. Barker, Louise S., Schoggen, M., Schoggen, P., Providing recreational and social outlets for and Barker, R. 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